1962822692 NPI number — CATHERINE PETZINGER DESHAZO D.O.

Table of content: CATHERINE PETZINGER DESHAZO D.O. (NPI 1962822692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962822692 NPI number — CATHERINE PETZINGER DESHAZO D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESHAZO
Provider First Name:
CATHERINE
Provider Middle Name:
PETZINGER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962822692
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1211 UNION AVE STE 330
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38104-6655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-478-0966
Provider Business Mailing Address Fax Number:
901-478-0951

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5480 GOODMAN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLIVE BRANCH
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38654-7902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-893-9815
Provider Business Practice Location Address Fax Number:
662-893-9888
Provider Enumeration Date:
04/21/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  26737 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208600000X , with the licence number: 5101020893 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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